The resident, identified as Resident #42, was supposed to receive humidified oxygen through a nasal cannula. Instead, staff gave the patient a non-rebreather mask connected to unhumidified oxygen from a room concentrator.
That equipment switch violated multiple facility policies and medical protocols. Non-rebreather masks require high-flow oxygen, typically 10 to 15 liters per minute, and a doctor's order to use. The resident's room concentrator couldn't provide that level of oxygen flow.
The Advanced Practice Registered Nurse interviewed on December 30 told inspectors that staff were expected to follow orders exactly as written. She said using a non-rebreather would require a doctor's order and high-flow oxygen that wouldn't be available from the resident's room oxygen concentrator.
The facility's Medical Director reinforced that expectation during her interview that afternoon. She told inspectors that oxygen should be administered to residents exactly as doctors ordered it. Resident #42 should have been receiving humidified oxygen if that's what was prescribed.
The Medical Director explained that a non-rebreather shouldn't be used with low-flow oxygen. Changing from the ordered nasal cannula to a different delivery method would require a physician's order.
Facility policy spelled out the proper use of non-rebreather masks. The equipment was designed to deliver high-flow oxygen through both nose and mouth, according to physician orders. The oxygen flow rate should maintain the reservoir bag at least one-third to one-half full during inspiration.
The policy specified that non-rebreathers are generally used for emergency situations and only for short periods.
ARK Healthcare provided appropriate respiratory training in 2025 that covered these protocols. The training materials correctly identified that non-rebreather use should be ordered by a provider and used with high-flow oxygen.
But the staff responsible for Resident #42's care never received that training.
The Licensed Practical Nurse caring for the resident hadn't attended the respiratory education sessions. Neither had the two Nursing Assistants assigned to provide the resident's care.
The training gap meant the three staff members handling Resident #42's oxygen therapy didn't know the facility's own policies about when and how to use different oxygen equipment.
They didn't understand that switching from a nasal cannula to a non-rebreather mask required a doctor's order. They didn't know that non-rebreathers need high-flow oxygen that the resident's room concentrator couldn't provide.
Most importantly, they failed to ensure the resident received the humidified oxygen that doctors had specifically prescribed.
The inspection found that the facility had written the right policies and provided the right training. But those safeguards failed to protect Resident #42 because the staff actually providing care hadn't received the education they needed.
The violation affected few residents but created the potential for actual harm, according to federal inspectors. Oxygen therapy mistakes can compromise a patient's breathing and recovery.
Federal inspectors documented the oxygen administration failures as part of a complaint investigation completed on December 30. The facility must correct the deficient practices and ensure all staff receive proper respiratory care training before handling oxygen equipment.
Resident #42 continued to receive oxygen during the inspection, though inspectors didn't specify whether the facility had corrected the humidification and equipment problems by the time they completed their review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ark Healthcare & Rehabilitation At Governor's Ho from 2025-12-30 including all violations, facility responses, and corrective action plans.